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ANOMALOUS PRESENTATION OF ACUTE CORONARY SYNDROME: SUCCESSFUL THROMBOLYSIS IN A PATIENT PRESENTING WITH INFERIOR STEMI AND ANOMALOUS RIGHT CORONARY ARTERY
2415 JACC March 21, 2017 Volume 69, Issue 11
FIT Clinical Decision Making ANOMALOUS PRESENTATION OF ACUTE CORONARY SYNDROME: SUCCESSFUL THROMBOLYSIS IN A PATIENT PRESENTING WITH INFERIOR STEMI AND ANOMALOUS RIGHT CORONARY ARTERY Poster Contributions Poster Hall, Hall C Sunday, March 19, 2017, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision‐Making: Interventional Cardiology, Acute and Stable Ischemic Heart Disease, and Vascular Medicine Abstract Category: Acute and Stable Ischemic Heart Disease Presentation Number: 1300-363 Authors: Shane P. Prejean, Firas Al Solaiman, Sumanth Prabhu, UAB Division of Cardiovascular Disease, Birmingham, AL, USA
Background: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus is rare, occurring in 0.15% of patients undergoing angiography and is a known cause of myocardial ischemia and sudden cardiac death. Studies suggest lower risk of sudden death in patients with anomalous right coronary artery arising from the left coronary sinus (ARCA) and in patients older than 30 years.
Case: A fifty-eight year old male with a history of hypertension presented with acute inferior ST-elevation myocardial infarction (STEMI), hypotension and complete heart block. He was taken for primary percutaneous coronary intervention (PCI); however, the right coronary artery was not identified. Temporary pacemaker and intra-aortic balloon pump were placed and the patient was given alteplase by intravenous bolus. The patient had resolution of ST elevation and return to normal sinus rhythm. CT angiography of the coronary arteries revealed ARCA with an interarterial course and slit-like orifice. The patient was discharged on appropriate medical therapy and was asymptomatic at 4 week follow-up. Pharmacologic SPECT myocardial perfusion imaging was normal. Exercise stress echocardiography is planned.
Decision‐Making: Primary PCI may be difficult or may not be possible in patients with coronary anomalies who present with STEMI. We demonstrate successful reperfusion with thrombolytic therapy after failed PCI. Coronary CT angiography and nuclear imaging were used to determine the patient’s anatomy and assess for persistent ischemia. Treatment options were discussed. After his initial presentation, the patient elected to continue medical therapy with plans for provocative testing to guide subsequent consideration of ARCA surgical repair.
Conclusions: Thrombolytic therapy can be used in patients with AAOCA presenting with STEMI in which primary PCI is unsuccessful. Follow-up testing should define coronary anatomy and guide decisions on therapy. Consideration should be given for surgical management as patients may remain at risk for recurrent ischemia and sudden death. Further prospective studies are needed to define risk of adverse events in patients with ARCA, especially in those older than 30 years.
FIT Clinical Decision Making ANOMALOUS PRESENTATION OF ACUTE CORONARY SYNDROME: SUCCESSFUL THROMBOLYSIS IN A PATIENT PRESENTING WITH INFERIOR STEMI AND ANOMALOUS RIGHT CORONARY ARTERY Poster Contributions Poster Hall, Hall C Sunday, March 19, 2017, 9:45 a.m.-10:30 a.m. Session Title: FIT Clinical Decision‐Making: Interventional Cardiology, Acute and Stable Ischemic Heart Disease, and Vascular Medicine Abstract Category: Acute and Stable Ischemic Heart Disease Presentation Number: 1300-363 Authors: Shane P. Prejean, Firas Al Solaiman, Sumanth Prabhu, UAB Division of Cardiovascular Disease, Birmingham, AL, USA
Background: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus is rare, occurring in 0.15% of patients undergoing angiography and is a known cause of myocardial ischemia and sudden cardiac death. Studies suggest lower risk of sudden death in patients with anomalous right coronary artery arising from the left coronary sinus (ARCA) and in patients older than 30 years.
Case: A fifty-eight year old male with a history of hypertension presented with acute inferior ST-elevation myocardial infarction (STEMI), hypotension and complete heart block. He was taken for primary percutaneous coronary intervention (PCI); however, the right coronary artery was not identified. Temporary pacemaker and intra-aortic balloon pump were placed and the patient was given alteplase by intravenous bolus. The patient had resolution of ST elevation and return to normal sinus rhythm. CT angiography of the coronary arteries revealed ARCA with an interarterial course and slit-like orifice. The patient was discharged on appropriate medical therapy and was asymptomatic at 4 week follow-up. Pharmacologic SPECT myocardial perfusion imaging was normal. Exercise stress echocardiography is planned.
Decision‐Making: Primary PCI may be difficult or may not be possible in patients with coronary anomalies who present with STEMI. We demonstrate successful reperfusion with thrombolytic therapy after failed PCI. Coronary CT angiography and nuclear imaging were used to determine the patient’s anatomy and assess for persistent ischemia. Treatment options were discussed. After his initial presentation, the patient elected to continue medical therapy with plans for provocative testing to guide subsequent consideration of ARCA surgical repair.
Conclusions: Thrombolytic therapy can be used in patients with AAOCA presenting with STEMI in which primary PCI is unsuccessful. Follow-up testing should define coronary anatomy and guide decisions on therapy. Consideration should be given for surgical management as patients may remain at risk for recurrent ischemia and sudden death. Further prospective studies are needed to define risk of adverse events in patients with ARCA, especially in those older than 30 years.